- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $40.58 / $44.63 / $44.63
| Facility | 26 | $40.58 | $44.63 | $44.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $107.05 / $115.90
| Professional | | $83.18 | $107.05 | $115.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $46.12 / $103.37
| Professional | | $43.65 | $46.12 | $103.37 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $46.68 / $46.68 / $46.68
| Facility | 26 | $46.68 | $46.68 | $46.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.34 / $102.55 / $288.70
| Professional | | $77.34 | $102.55 | $288.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.21 / $91.00 / $145.60
| Professional | | $60.21 | $91.00 | $145.60 |